It is official that Hoarding Disorder is recognised as a Mental Disorder in the DSM.

What is the DSM

The Diagnostic and Statistical Manual of Mental Disordersis the handbook used by health care professionals in the United States and much of the world as the authoritative guide to the diagnosis of mental disorders. DSM contains descriptions, symptoms, and other criteria for diagnosing mental disorders.

It provides a common language for clinicians to communicate about their patients and establishes consistent and reliable diagnoses that can be used in the research of mental disorders. It also provides a common language for researchers to study the criteria for potential future revisions and to aid in the development of medications and other interventions.

It was anticipated that the American Psychiatric Association (APA) spent $20 – $25 million on the extensive process of developing DSM-5. (3)

DSM – 5

Hoarding Disorder

Diagnostic Criteria

300.3 (F42)

A.

Persistent difficulty discarding or parting with possessions, regardless of their actual value.

B.

This difficulty is due to a perceived need to save the items and to distress associated with discarding them.

C.

The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, authorities).

D.

The hoarding causes clinically significant distress or impairment in social, occupational or other important areas of functioning (including maintaining a safe environment for self and others).

E.

The hoarding is not attributable to another medical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi syndrome).

F.

The hoarding is not better explained by the symptoms of another mental disorder (e.g., obsessions in obsessive-compulsive disorder, decreased energy in major depressive disorder, delusions in schizophrenia or another psychotic disorder, cognitive deficits in major neurocognitive disorder, neurocognitive disorder, restricted interests in autism spectrum disorder).

Specify if:

With excessive acquisition:If difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed or for which there is no available space.

Specify if:

With good or fair insight:The individual recognises that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic.

With poor insight:
The individual is mostly convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.

With absent insight/delusional beliefs:The individual is completely convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.

Specifiers

With excessive acquisition. Approximately 80% – 90% of individuals with hoarding disorder display excessive acquisition. The most frequent form of acquisition is excessive buying, followed by acquisition of free items (e.g., leaflets, items discarded by others).

Stealing is less common. Some individuals may deny excessive acquisition when first assessed, yet it may appear later during the course of treatment. Individuals with hoarding disorder typically experience distress if they are unable to or are prevented from acquiring items.

Diagnostic Features

The essential feature of hoarding disorder is persistent difficulties discarding or parting with possessions, regardless of their actual value (Criterion A). The term persistent indicates a long-standing difficulty rather than more transient life circumstances that may lead to excessive clutter such as inheriting property. The difficulty in discarding possessions noted in Criterion A refers to any form of discarding, including throwing away, selling, giving away or recycling.

The main reasons given for these difficulties are the perceived utility or aesthetic value of the items or strong sentimental attachment to the possessions.

Some individuals feel responsible for the fate of their possessions and often go to great lengths to avoid being wasteful.

Fears of losing important information are also common.

The most commonly saved items are newspapers, magazines, old clothing, bags, books, mail and paperwork but virtually any item can be saved. The nature of items is not limited to possessions that most other people would define as useless or of limited value.
Many individuals collect and save large numbers of valuable things as well, which are often found in piles mixed with other less valuable items.

Individuals with hoarding disorder purposefully save possessions and experience distress when facing the prospect of discarding them (Criterion B). This criterion emphasizes that the saving of possessions is intentional, which discriminates hoarding disorder from other forms of psychopathology that are characterised by the passive accumulation of items or the absence of distress when possessions are removed.

Individuals accumulate large numbers of items that fill up and clutter active living areas to the extent that their intended use is no longer possible (Criterion C).

For example – the individual may not be able to cook in the kitchen, sleep in his or her bed, or sit in a chair. If the space can be used, it is only with great difficulty. Clutter is defined as a large group of usually unrelated or marginally related objects piled together in a disorganized fashion in spaces designed for other purposes (e.g., tabletops, floor, hallway). Criterion C emphasizes the “active” living areas of the home, rather than more peripheral areas, such as garages, attics or basements, that are sometimes cluttered in homes of individuals without hoarding disorder.
However, individuals with hoarding disorder often have possessions that spill beyond the active living areas and can occupy and impair the use of other spaces, such as vehicles, yards, the workplace and friends’ and relatives’ houses. In some cases, living areas may be uncluttered because of the intervention of third parties (e.g., family members, cleaners, local authorities). Individuals who have been forced to clear their homes still have a symptom picture that meets criteria for hoarding disorder because the lack of clutter is due to a third-party intervention.

Hoarding disorder contrasts with normative collecting behaviour, which is organized and systematic, even if in some cases the actual amount of possessions may be similar to the amount accumulated by an individual with hoarding disorder. Normative collecting does not produce the clutter, distress or impairment typical of hoarding disorder.

Symptoms (i.e., difficulties discarding and / or clutter) must cause clinically significant distress or impairment in social, occupational or other important areas of functioning, including maintaining a safe environment for self and others (Criterion D). In some cases, particularly when there is poor insight, the individual may not report distress and the impairment may be apparent only to those around the individual. However, any attempts to discard or clear the possessions by third parties result in high levels of distress.

Associated Features Supporting Diagnosis

Other common features of hoarding disorder include indecisiveness, perfectionism, avoidance, procrastination, difficulty planning and organizing tasks and distractibility.

Some individuals with hoarding disorder live in unsanitary conditions that may be a logical consequence of severely cluttered spaces and / or that are related to planning and organizing difficulties.

Animal hoarding can be defined as the accumulation of a large number of animals and a failure to provide minimal standards of nutrition, sanitation and veterinary care and to act on the deteriorating condition of the animals (including disease, starvation or death) and the environment (e.g., severe overcrowding, extremely unsanitary conditions). Animal hoarding may be a special manifestation of hoarding disorder. Most individuals who hoard animals also hoard inanimate objects. The most prominent differences between animal and object hoarding are the extent of unsanitary conditions and the poorer insight in animal hoarding.

Prevalence

Community surveys estimate the point prevalence of clinically significant hoarding in the United States and Europe to be approximately 2%-6%. Hoarding disorder affects both males and females, but some epidemiological studies have reported a significantly greater prevalence among males. This contrasts with clinical samples, which are predominantly female.

Hoarding symptoms appear to be almost three times more prevalent in older adults (ages 55-94 years) compared with younger adults (ages 34-44 years).

Development and Course

Hoarding appears to begin early in life and spans well into the late stages.

Hoarding symptoms may first emerge around ages 11-15 years, start interfering with the individual’s everyday functioning by the mid-20s and cause clinically significant impairment by the mid-30s. Participants in clinical research studies are usually in their 50s. Thus, the severity of hoarding increases with each decade of life.

Once symptoms begin, the course of hoarding is often chronic, with few individuals reporting a waxing and waning course.

Pathological hoarding in children appears to be easily distinguished from developmentally adaptive saving and collecting behaviors. Because children and adolescents typically do not control their living environment and discarding behaviors the possible intervention of third parties (e.g., parents keeping the spaces usable and thus reducing interference) should be considered when making the diagnosis.

Risk and Prognostic Factors

TemperamentalIndecisiveness is a prominent feature of individuals with hoarding disorder and their first-degree relatives.

EnvironmentalIndividuals with hoarding disorder often retrospectively report stressful and traumatic life events preceding the onset of the disorder or causing an exacerbation.

Genetic and PhysiologicalHoarding behaviour is familial, with about 50% of individuals who hoard reporting having a relative who also hoards. Twin studies indicate that approximately 50% of the variability in hoarding behaviour is attributable to additive genetic factors.

Culture-Related Diagnostic Issues

While most of the research has been done in Western, industrialised countries and urban communities, the available data from non-Western and developing countries suggest that hoarding is a universal phenomenon with consistent clinical features.

Gender-Related Diagnostic Issues

The key features of hoarding disorder (i.e., difficulties discarding, excessive amount of clutter) are generally comparable in males and females but females tend to display more excessive acquisition, particularly excessive buying, than do males.

Functional Consequences of Hoarding Disorder

Clutter impairs basic activities, such as moving through the house, cooking, cleaning, personal hygiene and even sleeping. Appliances may be broken and utilities such as water and electricity may be disconnected, as access for repair work may be difficult.
Quality of life is often considerably impaired. In severe cases, hoarding can put individuals at risk for fire, falling (especially elderly individuals), poor sanitation and other health risks. Hoarding disorder is associated with occupational impairment, poor physical health, and high social service utilization.

Family relationships are frequently under great strain. Conflict with neighbours and local authorities is common and a substantial proportion of individuals with severe hoarding disorder have been involved in legal eviction proceedings and some have a history of eviction.

Differential Diagnosis

Other medical conditionsHoarding disorder is not diagnosed if the symptoms are judged to be a direct consequence of another medical condition (Criterion E), such as traumatic brain injury, surgical resection for treatment of a tumour or seizure control, cerebrovascular disease, infections of the central nervous system (e.g., herpes simplex encephalitis), or neurogenetic conditions such as Prader-Willi syndrome. Damage to the anterior ventromedial prefrontal and cingulate cortices has been particularly associated with the excessive accumulation of objects. In these individuals, the hoarding behaviour is not present prior to the onset of the brain damage and appears shortly after the brain damage occurs. Some of these individuals appear to have little interest in the accumulated items and are able to discard them easily or do not care if others discard them, whereas others appear to be very reluctant to discard anything.

Neurodevelopmental disordersHoarding disorder is not diagnosed if the accumulation of objects is judged to be a direct consequence of a neurodevelopmental disorder, such as autism spectrum disorder or intellectual disability (intellectual developmental disorder).

Schizophrenia spectrum and other psychotic disordersHoarding Disorder is not diagnosed if the accumulation of objects is judged to be a direct consequence of delusions or negative symptoms in schizophrenia spectrum and other psychotic disorders.

Major depressive episodeHoarding Disorder is not diagnosed if the accumulation of objects is judged to be a direct consequence of psychomotor retardation, fatigue or loss of energy during a major depressive episode.

Obsessive-compulsive disorderHoarding Disorder is not diagnosed if the symptoms are judged to be a direct consequence of typical obsessions or compulsions, such as fears of contamination, harm or feelings of incompleteness in obsessive-compulsive disorder (OCD). Feelings of incompleteness (e.g., losing one’s identity or having to document and preserve all life experiences) are the most frequent OCD symptoms associated with this form of hoarding.
The accumulation of objects can also be the result of persistently avoiding onerous rituals (e.g., not discarding objects in order to avoid endless washing or checking rituals).

In OCD, the behavior is generally unwanted and highly distressing and the individual experiences no pleasure or reward from it. Excessive acquisition is usually not present; if excessive acquisition is present, items are acquired because of a specific obsession (e.g., the need to buy items that have been accidently touched in order to avoid contaminating other people), not because of a genuine desire to possess the items. Individuals who hoard in the context of OCD are also more likely to accumulate bizarre items, such as trash, faeces, urine, nails, hair, used diapers, or rotten food. Accumulation of such items is very unusual in hoarding disorder.

When severe hoarding appears concurrently with other typical symptoms of OCD but is judged to be independent from these symptoms, both hoarding disorder and OCD may be diagnosed.

Neurocognitive disordersHoarding disorder is not diagnosed if the accumulation of objects is judged to be a direct consequence of a degenerative disorder such as neurocognitive disorder associated with frontotemporal lobar degeneration or Alzheimer’s disease.

Typically, onset of the accumulation behaviour is gradual and follows onset of the neuro-cognitive disorder. The accumulating behaviour may be accompanied by self-neglect and severe domestic squalor, alongside other neuropsychiatric symptoms, such as disinhibition, gambling rituals/stereotypies, tics and self-injurious behaviors.

Comorbidity

Approximately 75% of individuals with hoarding disorder have a comorbid mood or anxiety disorder. The most common comorbid conditions are major depressive disorder (up to 50% of cases), social anxiety disorder (social phobia) and generalized anxiety disorder.
Approximately 20% of individuals with hoarding disorder also have symptoms that meet diagnostic criteria for OCD.
These comorbidities may often be the main reason for consultation because individuals are unlikely to spontaneously report hoarding symptoms and these symptoms are often not asked about in routine clinical interviews. (4)

This above section spells out what the American Psychiatric Association are saying about Hoarding Disorder.

What we know is that it does exist and it is a mental disorder.

But are there those who are not diagnosed as so many in society have this tendency to accumulate and collect stuff over the years and it ends up cluttering our homes, garages, sheds and outbuildings.

Dear World

What if we got to the root issue of why and when we started hoarding.

Would that be the beginning of the healing process because we nominated and established where it came from in the first place.

What if imposing and expecting someone to Let Go and change is not the answer because there is more to consider about hoarding.

There is much in this world that we simply accept and never get round to addressing until it gets really serious.

Comments 2

A house clearance firm removed 12 tonnes of rubbish where the tenant was a pensioner living with a relative who was hoarding clutter for 30 years until she died.

The compulsive hoarding got worse when their partner died.

There were piles of clothes, shoes, books, umbrellas and rotting food cans, which had been there so long, the contents had vanished and the tins were crumbling.

It took 6 men 7 days to clear the enormous amount of clutter.

The job was carried out with no profit being made by Klutter King and the owner mr. Porter said he set up the company to make a living but has now seen the massive difference it can make to people’s lives.

House removals of this kind are now becoming big business and we need to get to the root cause of what happened that led to the accumulating of items and not discarding or moving on from them.

This blog gives us a great insight and presents us with a catalogue of questions that are well worth considering.

Holding on and not letting go are deep rooted and judging another for the way they lived or are living is not going to get us closer to having an understanding.

There is more we need to know and learn about WHY anyone subscribes to Hoarding and what is really behind the movements that continue thereafter.

Reflecting recently on someone who died last year, leaving a big house full of clutter, I know that it troubled them towards their end of life as they wanted to be letting go but did not have the resources. No one was interested to help and support them with this giant task of letting go and the job was way too much for them to deal with in their old age and ill health.

Their life story gives a real indication why their behaviour was such and that shopping constantly, buying and hoarding became as their best friend said their “business”.

It was not a hobby – it was a business.

They would buy things, give things away, accumulate things and transport them to their second home. This went on for 5 decades with 2 homes full of clutter, which have yet to be dealt with.

Their elderly partner who survives them is struggling and unable to continue living in either of the 2 homes.

One of the first things they wanted after the death was to have the house cleared of clutter, but it is yet to be actioned one year late due to the siblings in conflict following the death.

This true real life story is the norm, as so many families have this type of stuff going on.

We all need to sit down and question HOW ON EARTH have we got to this point, where a parent dies leaving a house full of clutter and the adult children behave in a way that is grossly irresponsible and dis-respectful to the surviving parent, by not honouring their wish to have the clutter removed as throughout the decades this person did not have a hoarding issue but instead, had an unspoken arrangement to live with this.

I would not have classed myself as a hoarder, however, reading this blog has asked me to consider the possibility that I might be.

This is because I have more clothes than I need and have run out of clothes’storage space.

In recent months, I have asked myself after making some clothes purchases whether I really needed the item of clothing or whether I had only made the purchase out of a need for a hit of dopamine – the reward or pleasure neurotransmitter that fires when we experience something salutary.

Now, having read the descriptors of excessive consumption above, I am beginning to wonder if I am actually a hoarder.

Whether I am a hoarder or not, one very useful thing has come to me through reading this blog.

Something has just come to me!
It seems obvious now, but I have only just realised that I have an investment in having the right clothes for every occasion and feeling good in what I wear each day.

Furthermore, that investment in having plenty of good clothes doesn’t feel so great right now because, although having good clothes is important, I should be able to feel great about myself no matter what I wear.